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Internal medicine (IM) patients are mostly elderly, with multiple complex co-morbidities, usually chronic. The complexity of these patients involves the intricate entanglement of two or more systems (e.g. body and disease, family-socio-economic and environmental status, coordination of care and therapies) and this requires comprehensive, multi-dimensional assessment (MDA). Despite attempts to improve management of chronic conditions, and the availability of several MDA tools, defining the complex patient is still problematic. The complex profile of our patients can only be described through the best assessment tools designed to identify their characteristics. In order to do this, the Federation of Associations of Hospital Doctors on Internal Medicine FADOI has created its own vision of IM. This involves understanding the different needs of the patient, and analyzing diseases clusters and the possible relationships between them. By exploring the real complexity of our patients and selecting their real needs, we can exercise holistic, anthropological and appropriate choices for their treatment and care. A simpler assessment approach must be adopted for our complex patients, and alternative tools should be used to improve clinical evaluation and prognostic stratification in a hierarchical selection of priorities. Further investigation of complex patients admitted to IM wards is needed.

A través de tres momentos históricos este artículo analiza aspectos de la circulación internacional de expertos, conocimientos y modelos institucionales que vincularon a la Higiene con la Cuestión Social en Argentina en el siglo XIX y principios del XX. Resalta la gran movilidad a la vez que el eclecticismo temprano y permanente con los que se formaron redes y se incorporaron conocimientos.

Background: Internal medicine has been defined as the specialty of the adult medical complex patients. Complexity science suggests that illness (and health) results from complex, dynamic, and unique interactions between different components of the overall system. In a patient, complexity involves the intricate entanglement of two or more systems (e.g.; body-diseases, family, socioeconomic status, therapies). Aim of the study: To evaluate the real applicability of Evidence Based Medicne (EBM) in clinical Departments of Internal Medicine and its critical perspectives. Discussion: Habitually the internist takes decisions in these situations: a) certainty (the ideal decision is adopted and the corresponding strategy follows), b) risk (the more suitable alternative selected can be the determination of the probable value or mathematical hope) and c) uncertainty, in which decisions linked to triple agents: beliefs and personal values of the doctors (I) for their patients (II) in the society (III). In the medical decisions there are often different factors that go beyond the field of technical and scientific knowledge (family, social, economic problems, etc.) and demanding an ethical analysis of the decision. Conclusions: The ‘‘evidence-based medicine’’, as other models of care, has — in itself — some limitations. ‘‘No evidence in medicine’’ matters that the postulates of the EBM are not always applicable to the real patients of Internal Medicine wards, mostly elderly, frail, complex, with comorbidities and polipharmacy, often with cognitive dysfunction and limitation of autonomy, with psycho-emotional, social and economic problems. The interacting effects of overall involved diseases/factors and their management require more complex and individualised care than simply the sum of separate guideline components. Further innovation is required to resolve the need to enhance integration of evidence with our patients’ values at the ‘‘bedside and/or clinic’’ management.

Introduction: Subcutaneous manifestations of severe acute pancreatitis (Cullen’s sign, Gray- Turner’s sign, Fox’s sign, and Bryant’s sign) are often discussed in journals and textbooks, but seldom observed. Although historically associated with acute pancreatitis, these clinical signs have been described in various other conditions associated with retroperitoneal hemorrhage. Case report: We describe the case of a 61-year-old male with no history of alcohol intake, who was admitted for epigastric pain, vomiting, and increasing serum amylase and lipase levels. Five days after admission, ecchymotic skin discoloration was noted over both flanks (Gray-Turner’s sign) and the upper third of the thighs (Fox’s sign). Ten days later, he developed multiorgan failure and was transferred to the ICU for 5 days. Computed tomography revealed a large pancreatic fluid collection, which was subjected to EUS-guided drainage. Cholecystectomy was later performed for persistent obstructive jaundice. After more than 4 months of hospitalization, he died as a result of severe gastrointestinal bleeding. Discussion and conclusions: Skin manifestations of retroperitoneal hemorrhage in a patient with acute pancreatitis indicate a stormy disease course and poor prognosis. The severity of acute pancreatitis is currently estimated with validated scoring systems based on clinical, laboratory, and imaging findings. However, skin signs like the ones discussed above can represent a simple and inexpensive parameter for evaluating the severity and prognosis of this disease.

Introduction: Chronic obstructive pulmonary disease (COPD) is the second leading cause of hospitalization in Internal Medicine departments in Italy and the fourth leading cause of death all over the word. By 2020, COPD will be the third leading cause of death and the fifth leading cause of disability. It is — along with chronic congestive heart failure — one of the most common causes of unscheduled hospital readmissions, and as such it represents a significant economic burden for the health-care system. Exacerbations of COPD are important events in the natural history of this prevalent condition. Discussion: This review provides a comprehensive state-of-the-art look at prevention and management of COPD exacerbations. Treatment of these episodes has to be tailored to the severity of the clinical presentation. We now have a wide range of therapeutic available options, based on the results of clinical trials. Management of the acute event should include the necessary measures (mainly the administration of inhaled short-acting bronchodilators, inhaled or oral corticosteroids, and antibiotics), with or without oxygen and ventilator support. Conclusions: To improve the management of COPD exacerbations, the focus of care must be shifted from the episodic acute complications to their systematic prevention. The management of COPD, which is often associated with multiple co-morbidities, is complex and requires a tailored, multifaceted and multidisciplinary approach. Integrated care for COPD also requires that patients be informed about their condition, that they participate actively in their care, and that they have easy access to the necessary health-care services.

Introduction Ortner's syndrome, also known as cardiovocal syndrome, is a rare clinical entity with hoarseness due to left recurrent laryngeal nerve (RLN) palsy owing to a cardiovascular disease. Norbert Ortner ascribed hoarseness of voice RLN palsy in patients with several mitral stenosis, postulating that an enlarged left atrium could be responsible for the recurrent laryngeal nerve palsy. Case report A 63-year-old man with a history of progressive hoarseness of voice developed since over three months. Flexible laryngoscopy revealed a fixed left vocal cord in the paramedian position. The chest enhanced axial computed tomography confirmed a large left ventricular aneurysm. Conclusions Hoarseness has significant public health implications. Patients suffer from social deprivation, depression and a poor quality of life. Several underlying conditions are associated with the cardiovocal syndrome, including iatrogenic, congenital, mitral valve disorders, aortic and ventricular aneurysms. Laryngoscopy is indicated for the assessment of hoarseness if symptoms fail to improve or resolve within three months, or at any time when the clinician suspects a serious underlying disorder.

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Hazard-prone areas in southern Africa experience many natural hazards, which include cyclones, floods and droughts. The severe climatic conditions of southern Africa have an especially large impact on the agricultural practices of small-scale farmers. These hazards should be mitigated to ensure more resilient communities and food security. This study mainly focuses on the timing of agricultural production in hazard-prone areas to prevent losses at peak-risk periods by adapting the agricultural cycle. This study focuses on the agricultural activities of small-scale farmers in Malawi, Madagascar and Mozambique. A literature review is presented, and a mixed-method research design were followed to determine the timing of production followed by these small-scale farmers and its impact on production and food security. Although this study found that the small-scale farmers generally plant with the first rains, it is recommended by literature that early planting should be practised to ensure optimal production. It is also recommended that small-scale farmers should implement watermanagement techniques for dry periods, and when farmers practice late planting, the use of residual-moisture retention should be utilised as a mitigation measure. This will in effect ensure that the communities are less vulnerable during peak-risk periods by improving or ensuring food security. Therefore, adapting the planting and production time in these hazardprone areas at peak-risk periods could limit losses and increase communities’ resilience.